Psychiatrists Who Volunteered After Katrina Look Back on Lessons
Abstract
Geared up in a hurry, a program to send psychiatrists to the Gulf after Katrina mostly worked well but imparted some lessons. This is the second of a two-part series marking the 10th anniversary of hurricanes Katrina and Rita.
After hurricanes Katrina and Rita hit the Gulf Coast region in August and September 2005, much of the mental health infrastructure was inoperable. Clinics and hospitals in some places were damaged and unusable. Clinicians of all kinds and their patients were forced to evacuate from cities like New Orleans and Gulfport, Miss. At the same time, the trauma for survivors arising from the loss of homes, jobs, and loved ones raised calls for help from outside the region.
As the storm approached, Louisiana mental health officials formally requested outside assistance from the Federal Emergency Management Agency (FEMA), said Anthony Speier, Ph.D., then disaster director for the Louisiana’s state mental health department. Even with the lead time, six weeks were needed to set up the program, partly due to a shift in responsibility from FEMA to the Substance Abuse and Mental Health Services Administration (SAMHSA). That agency needed to set up a clearinghouse to vet volunteer clinicians and organize a system to house and feed them while on site.
Humility and Flexibility: Keys to Effective Disaster Response
In 2005 Edward Kantor, M.D., then at the University of Virginia, helped with a plan to receive refugees from Louisiana while serving as the Psychiatric Society of Virginia disaster liaison and chief of the University of Virginia’s Medical Reserve Corps. Kantor helped coordinate mental health planning and supports after 9/11, the Virginia Tech shooting in 2007, and the recent church shooting in Charleston, S.C., where he is now an associate professor of psychiatry at the Medical University of South Carolina. Today, he continues to reflect on the disconnects in response planning from the Katrina response that still persist:
The strangest part of Katrina from my perspective was that every agency started recruiting and building rolls of potential responders. That sometimes made what happened more about the agency than the response and created confusion because everything happened in parallel. In a few instances, it worked against systems already in place for calling up and deploying volunteers.
However, Katrina also reemphasized what we learned after 9/11—that licensed professionals needed some sort of registration and prescreening when possible. This is even more important in events related to violence or terrorism where access is more highly regulated.
In contrast, some incredible things also happened that had never been pulled off before in terms of interagency cooperation—like an in-the-moment Memorandum of Understanding between the Medical Reserve Corps and the American Red Cross for utilization of volunteers. That was unprecedented. There are also lots of stories of spontaneous volunteers who simply decided to show up and had no role.
Psychiatry’s role has and will continue to vary greatly based on the person, the event, and the regional particulars. Having a role before the event helps facilitate participation during and after. Basic training in disaster issues and operations, as well as pre-credentialing and registration, all help to ensure useful participation and minimize frustration.
I think the best examples of psychiatry working in disaster areas occur when we go in humbly and want to help, rather than treat, and can tolerate not being in charge of everyone and everything.
Figuring out where we can fit in and amplify the overall response takes ongoing flexibility from professional societies. An individual psychiatrist well versed in response issues can be a great help with risk-communication message development, supporting leaders and responders, and developing local strategies across the existing resources and agencies. Getting along and respecting the value and expertise of our non-psychiatrist colleagues is paramount for successful integration. Respecting the population affected, partnering when possible with local clinicians, and having sensitivity to cultures and beliefs different from our own are all critical to success.
If I’ve learned anything, it’s that preexisting relationships and trust between the individuals involved still go much further than titles and predefined roles when getting groups to play together and in making things work in the midst of the inevitable chaos.
Meanwhile, APA’s Committee on the Psychiatric Dimensions of Disaster worked to reconnect area psychiatrists with each other, temporarily providing a remote organizational structure, since local district branches in Louisiana, Mississippi, and Texas could not function.
“They had excellent resources in the area, and we backed them up,” recalled Robert Ursano, M.D., the current chair of the committee and a professor and chair of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md.
Anthony Ng, M.D., then chair of APA’s disaster committee, went to Gulfport, Miss., following Katrina. Ng learned a lot about postdisaster psychiatry while working in New York City after September 11, 2001.
“In Gulfport, I met with local providers and people from the University of Mississippi to help with training in disaster psychiatry,” said Ng, now CMO at Acadia Hospital and chief of psychiatric services at Eastern Maine Medical Center in Bangor.
APA also worked with SAMHSA to recruit mental health professionals to go south. The visitors generally served for a few weeks each in shelters or other points of refuge for displaced citizens.
Today, many of those who went to the region look back with a nuanced view of their experience.
“The SAMHSA program was surprisingly well organized in the face of general chaos,” said Jeffrey Stovall, M.D., now an associate professor of psychiatry at Vanderbilt University. “We probably achieved some individual success but didn’t have much impact on rebuilding the system of care. It’s more important to have an organized response.”
At the New Orleans airport after the storm, Laurence Hipshman, M.D., M.P.H., now a psychiatrist with Kaiser Permanente in Portland, Ore., was a member of a Disaster Medical Assistance Team, doing triage for medical evacuation. Organization and coordination were erratic, he said.
“We worked with other units sent in to help, like the National Guard, but we had to make many things happen on our own,” he said, recalling, like others, the chaos of the first few days. “There was no regular source of pharmaceuticals, so we had to cobble something together on our own. People with no supplies were gathering outside the airport, creating tensions over who could get food or services.”
Washington, D.C., psychiatrist Catherine May, M.D., made five trips to the region in the year or so after the storms. She worked on a cruise ship rented by FEMA that housed first responders and their families and later served at an Episcopal tent clinic started by a nurse in Pass Christian, Miss.
May, who first trained as an emergency physician, observed that close to 50 percent of people with initial physical complaints also screened positive for posttraumatic stress disorder (PTSD) and other psychiatric symptoms. From that she concluded that even basic, hands-on general medical skills like taking vital signs or asking how a patient was feeling could open doors to mental health counseling or treatment.
Resilience Triumphs
At least one psychiatrist became an exile and a volunteer simultaneously. Before Katrina, Harold Ginzburg, M.D., J.D., was a former U.S. Navy doctor in private practice in Metairie, La., a New Orleans suburb. Today he works at the Muskogee, Okla., Veterans Affairs Hospital.
In September 2005, he recounted to APA’s Assembly the story of his own hurried departure from Metairie to a summer camp near Utica, Miss., housing storm refugees, where he quickly became the camp doctor.
Like many others, Ginzburg observed the resilience of his fellow exiles even in times of great hardship. There was a paradox in the conventional wisdom about the psychological effects of a disaster like Katrina, he said.
“People can still meet the criteria for PTSD without being dysfunctional,” he said. “They can still show up for work.”
Katrina also reemphasized the lessons learned after 9/11, namely, that licensed professionals needed some sort of registration and prescreening when possible.
“Spontaneous volunteers are not useful,” said Leslie Gise, M.D., of Kula, Hawaii, who came to New Orleans two weeks after the storm. “My experience at Katrina made me realize that all the seemingly boring courses on psychiatric disaster response that I sat through over the years were actually of value.”
“I learned the importance of preparedness,” said Elizabeth Henderson, M.D., who went from her home in Jackson, Miss., to Gulfport after the storm. One area that is often overlooked is the emotional status of first responders, especially when they are getting appeals for help and cannot respond. “They need time out to remain effective.”
“Much of the time the system worked well,” said Howard Osofsky, M.D., Ph.D., a professor and chair of psychiatry at Louisiana State University Health Sciences Center in New Orleans. “But sometimes there were problems of discontinuity in their relationship with local providers as volunteers arrived or left abruptly.”
Volunteer psychiatrists who came to Louisiana and Mississippi after hurricanes Katrina and Rita in 2005 helped play a role in getting local mental health services back to work, said Howard Osofsky, M.D., Ph.D.
Many individual clinicians were well intentioned but were not well prepared for the rigors of postdisaster psychiatry, like makeshift accommodations or the large numbers of people seeking help, added Speier. “There has to be better orientation of where they’re going, and that can’t be handled right before they arrive.”
Psychiatrists who worked in the affected areas emphasized the resilience and the variety of the people they encountered.
“The experience clarified for me both the vulnerabilities of the patients we serve and also the strength of communities to take care of themselves,” said Stovall.
May gained an appreciation of working with faith-based groups.
“I learned to value the positive, cognitively based structure of those organizations,” she said. “That’s how you infuse hopefulness and a sense of purpose.”
Insight into people on a higher level than the individual is needed, as well, said Osofsky. “Clinicians need an understanding of culture—or cultures—in the communities where they serve.”
May offered another lesson about disaster response. She observed that there is a time to go in and work, but there comes a time to leave, because the region has its own existing resources. “They get back up in action, and you’re not needed there anymore,” she said.
Today, there may be a greater awareness of what needs to be done after a disaster, but that awareness is not matched by an increase in community preparedness, said Ng.
Mental health professionals need to assert their role in the preplanning stages of disaster response, said Henderson. “Mental health is the last thing planners think about and the first thing that they miss when disaster happens.” ■
